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SAN JOZw4IN COUNTY PUBLIC HEALTH SE-...,:CES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County ,�Public Health Services. /' Job Address / S' •S - �A'gpl[NG n_Ciry JTOGC�1t Lot Size/Acreage Owner's Name e1MY2ON 6CSA 4/sacc"-C4ddrrjess oZ#/O C41--";,rid 1Qam,0n Q' Phones/a 9 L-%Zo ContractorV I L-*�-*��CG- Address/my 6"".L License No. �J 7 Phones/c' 3 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT Fl DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio — Dia. of Well Casing r t^ `<Domestic/Private 0 Gravel Pack7 0 Tracy Type of Casing_ 10, _,G� Specifications �J I'I Public Other Fl Delta Depth of Grout Seal N� Type of Grout C44124241-1" (l I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION 1 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments AN PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ��' APR R i�9�. LEACHING LINE 0 No. & Length of lines Total length/size CC I FILTER BED Cl Distance to nearest: Well Foundation Property Line PU3LIC HEALTI SER cr,!VIR01NMFINTAL HE ALih. SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant nj&4st call for all required inspections. Complete drawing onreverseside. Si ened �� 4 �L �a' ��— Title: _:(,T.�LOC7/C % Date: e' 9 Z OR DEPARTMENT USE ONLY Application Accepted by Date q2- Area Of', '12 gv Final Inspection by // Date Pit or Grout Inspection by Date Additional Comments: VVV Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �(� �/•'J� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH EH 17.3 IREV.vn3t 00 ©�-- to-4Gl q I1'l YY� 5 �l 42 n,70490 EH tt-m